Ask Adele- Let's Talk Pop Health: The Cost of Doing it Right

Question:Safety net providers are challenged to reduce disparities in care. How can health IT be used to truly make a difference? Are there limits or opportunities?

Answer:

Disparity reduction needs to be on your radar for two major reasons. First, it is the right thing to do. Health equity is described by the CDC as everyone’s opportunity to “attain his or her full health potential,” regardless of an individual’s social circumstances or position. In 2002, the Institute of Medicine (IOM) published a report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, linking health inequity to minorities and launching the U.S. Department of Health and Human Services (HHS) annual disparity reporting. The health of the nation is being tracked.

Second, healthcare economics demands it. The estimated costs of racial and ethnic disparities were estimated to be around $1.24 trillion from 2003 through 2006, between direct and indirect totals, according to a report by the Joint Center for Political and Economic Studies. In 2009, the Urban Institute estimated costs for chronic disease and disparity to be $23.9 billion, 65 percent of which was borne by state Medicaid programs. Furthermore, these annual costs are projected to reach $50 billion by 2050 as minorities join the ranks of our aging population.

Value-based payment (VBP) is the objective of a growing movement under payment reform. Providers are being measured on quality and efficiency to determine the “value” of care rendered to defined patient populations. Addressing only the patient that presents for care is no longer sufficient. VBP measures span the health of entire populations and are driven by evidence and research. High data performers will be rewarded and low data performers will be negatively adjusted. But, here’s the rub: Multiple determinants factor into the health of a population, and not all of them are being adequately addressed and measured.

Health Determinants

While the minutiae of subcategories may be endless, the CDC recognizes five major factors that impact the health of a defined population:

Not to minimize treatment of patients, the services a provider actually renders is one of the smallest factors actually influencing the patient’s health and well-being. According to a report by the Center for Health Care Strategies and the Institute on Urban Health Research and Practice, healthcare services have only a ten percent influence on the health status of a patient. Ergo, the other categories may play a bigger role: Behavior (40 percent), genetics (30 percent), social status (15 percent), and environment (five percent). Think about it. A provider may have three different patients with the same health status for which he is rendering treatment → metabolic disease. However, the drivers influencing these conditions are likely completely different → patient 1 because of poor eating and obesity; patient 2 because he doesn’t exercise; and, patient 3, who exercises and eats right, has bad genetics.

Consumerism and Patient Profiling

Today, more of the first dollar payment is coming from patients directly. KFF recently reported that average yearly out-of-pocket costs for employees grew by 230 percent from 2006 to 2015. Additionally, the insurance marketplace offers “bronze” level coverage, affording just 60 percent in benefits and resting 40 percent of the costs squarely on the shoulders of the beneficiary. Combined with the “Internet of things,” healthcare consumerism has increased – patients’ desire to be knowledgeable about services, treatment options and the providers who perform them before engaging.

Beyond the fact that patients are seeking more information online, according to the Commonwealth Fund, consumer profiling can have a substantial impact on a patient’s understanding, adherence, and ultimate health. With behavior and social determinants representing over half of the factors influencing health, using tools to profile patients as healthcare consumers makes incredible sense. The Commonwealth reports there are five to six types of patient profiles in the U.S., typically:

·High interest in health and wellness, but values provider advice less than Self-Achievers

·DIY health solutions such as “look what I found on the Internet”

Care options and involvement in making a joint decision based on the pros and cons of each choice

Priority Jugglers

18%

·Their personal health is a secondary priority to busy lives and the health of their loved ones

·Personal health is only dealt with when the condition impedes the above philosophy

Emphasize self-care because so many others are depending on them

Direction Takers

13%

·“My provider knows what is best”

·Goes to doctor at first sign of a problem

·Adherent unless major barriers interfere

Tell them what you recommend and they will be happy to follow orders

Performing simple profiling of patients can determine the right message or approach to support adherence and behavior change. Many electronic health records (EHRs) offer customizable user-defined fields that allow users to configure and track structured data (e.g. education levels). Perhaps such an IT tool can be adapted to track a patient-consumer profile. Alternatively, some robust, structured nomenclatures used for encounter documentation (e.g., Medcin) may offer findings that can be added to a template for structured data capture and profiling purposes. Once structured data is assigned to a patient, the ability to alert or incorporate such findings into outreach messaging can be used within the EHR.

Population Accountability and Value-Based Payment

Interest in health equity has existed for years, but healthcare disparity awareness took on new meaning when the value-based payment (VBP) truly emerged under healthcare reform. Initiated under the Affordable Care Act (ACA) and strengthened under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), providers will be paid on a go-forward basis under one of two payment paths: 1 – Risk-based management under Alternative Payment Models (APMs) such as an accountable care organization (ACO), bundled payments and capitation; or, 2 – fee-for-service (FFS) with differential adjustment based on measures of quality and efficiency. Regardless of the model, providers must be aware of the burdens assumed for a defined patient population for which they are held accountable.

Payer patient populations are typically “case mix adjusted” based on a complexity profile. More and more, patient profiles are being developed using data beyond claims data, such as pharmaceutical and lab data. Nevertheless, unlike retail giants like Target and Amazon, healthcare VBP does not incorporate non-healthcare data sources into patient profiling. Furthermore, current measures of quality and efficiency are typically process-oriented (e.g., number of flu shots provided) and cost-oriented (e.g., spend per beneficiary for an episode of care). But while population health management value grows with richer data, non-healthcare sources of data can be costly and difficult to obtain.

Increasingly, state Medicaid agencies are contracting with ACO-like organizations, making the need for providers to profile the patients for whom they will be accountable, a crucial issue to succeed. Today, over 71 million people are covered under Medicaid or CHIP. Medicaid costs typically represent 23-24 percent of a state’s total budget. The ACO model represents a cost-containment solution, with most arrangements built on a pre-arranged capitation amount for a defined scope of services. While most states are early in the planning and organizing process, according to a report by Leavitt Partners, 11 states are well down the ACO path, and population health analytics are deemed a cornerstone IT process necessary for success.

What can you do today?

Healthcare has not caught up to other industries in its use of real-time data. Nonetheless, here are five tips that I would offer today to support reimbursement and population health management.

1.Code with specificity. We have finally moved to ICD-10. Work on leveraging this plethora of nearly 70,000 patient classifications to communicate the nuances of your patient population to your payer.

2.Focus on Meaningful Use data capture. There are 22 structured data-points you should be capturing under Meaningful Use, including labs, smoking status, vitals, language preference, etc. Are you using this data to analyze potential barriers? Areas of high-risk? Your certified EHR should have the ability to identify risky patients for outreach and adherence tracking.

3.Capture data consistently. Once you understand the data you need for reporting purposes, internal use or research, map and train to a workflow that ensures the data is captured each and every time you connect with a patient. If they are coming in for an upper respiratory problem, when did they get their last flu shot?

4.Track patient adherence. Again, if you are using a 2014 edition certified EHR, make sure you are using the technology to generate lists of patients who are non-adherent to a critical guideline. Use this list for outreach to reduce disparities and promote adherence.

5.Always focus on patient engagement. Working with your patients as part of the care team is the first step in understanding how to impact their health. Listen to your patients. Incorporate their needs and preferences into clinical decision-making. Not only can this produce revealing information about your patient, but patient-centered activities also allow the right message to be delivered and promote patient retention.

Thank you for your question!

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This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U58CS06846, "S/RPCAs," total award $950K, with 65 percent of program funded by nongovernmental sources. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.